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dental asymmetries
Edsard van Steenbergen, DDS, MDS" and Ravindra Nanda, BDS, MDS, PhD b
Farmington, Conn.
Correction of dental asymmetries requires special attention in orthodontic treatment. Several types
of asymmetries are described, along with the biomechanics needed for correction. Treatment with
different appliance designs that correct these asymmetries with the lowest level of negative
contribution from side effects will be compared with conventional treatment. (AM J ORTHOD
DENTOFAC ORTHOP 1995;107:618-24.)
Fig. 1. A, 0.017 x 0.025-inch TMA intrusion arch comes from molar auxiliary tube and is tied to one
side of anterior segment (0.018 x 0.025-inch stainless steel) delivering intrusive force on that side.
B, Activated intrusion arch, before ligation on anterior segment. C, Intrusion arch tied in on one side
only.
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CLASSIFICATION
Dental asymmetries in orthodontics can be divided
into four groups:
1. Diverging occlusal planes
2. Asymmetric left to right buccal occlusion,
with or without midline deviation
3. Unilateral crossbite
4. Asymmetric arch form
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i
Fig. 3. A, Diagrammatic representation of unilateral extrusion
of canted anterior segment. 0.017 0.025-inch TMA cantilever coming from auxiliary tube of molar is tied to one side of
anterior segment. B, Patient with canted maxillary occlusal
plane. C, Correction of canted occlusal plane with cantilever
hook tied on affected side.
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Fig. 6. A, Diagram of force system delivered by 0.032 x 0.032-inch TMA transpalatal arch. B, C, and
D, Transpalatal arch should be activated by making gradual bends instead of sharp bends to deliver
desired force system. E through G, Patient with asymmetric buccal occlusion and deep bite. First
stage of treatment was correction of deep overbite by intrusion of maxillary incisors and simultaneous
correction of asymmetric buccal occlusion by tipping maxillary left molar and mandibular right molar
back. H, Anterior view of three-piece intrusion arch. Tip-back moment on the right side will counteract
the tip forward moment from transpalatal arch. Tip-back moment on left side adds to tip-back moment
from transpalatal arch.
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Fig. 6. Continued. I, Spaces have opened on maxillary left premolar and molar area. d, Space has
opened up between mandibular right first molar and second premolar because of tip-back activation
of lingual arch. To prevent mesial tipping on left side, heavy stainless steel arch wire extends from left
molar to the right second premolar. K and L, Right and left buccal view of the three-piece intrusion
arch. Note symmetric molar occlusion.
Fig. 6. Continued. M through O, After correction of molar asymmetry, teeth are individually tipped
with powerchain. Teeth in buccal segments were rebracketed parallel to occlusal plane. On maxillary
left side, continuation of space closure is required followed by rebracketing of canine. Note symmetric
buccal occlusion and coincident dental midlines. Remainder of Class II malocclusion was then
corrected with headgear mechanics.
rotation. Rotated molars are frequently seen in the maxillary arch. A mesial-in rotation of one molar often
results in an asymmetric molar occlusion. To correct this
problem, a transpalatal arch is used with equal amounts
of antirotation activation. An 0.018 0.025-inch stainless steel wire is tied into all teeth except the rotated
molar 16 (Fig. 7).
Clinical example C: no difference in molar rotation
and~or axial inclination. The right and left molar rela-
tionship can be asymmetric without perverted axial inclinations or rotations. A conventional approach to correct
this problem is to use an asymmetric headgear. 22 This
headgear has the potential to move one molar further
distally than the other molar. However, the transverse
components of the forces exerted by this appliance23 can
cause undesirable side effects. Good patient cooperation
(wearing the headgear) is necessary for this approach to
succeed.
"
Steenbergen and N a n d a
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Fig. 8. Diagram representing force system needed to correct unilateral dental crossbite. Force system can be delivered
by 0.032 x 0.032-inch TMA transpalatal arch that exerts expansive force on both molars and buccal root torque
on untipped molar. Moment to force ratio on correct side
should be 10 or larger to prevent this side from tipping
buccally.
SUMMARY
T h e m e c h a n i c s d e s c r i b e d h e r e i n a r e n o t all
inclusive for all d e n t a l a s y m m e t r i e s e n c o u n t e r e d in
p r a c t i c e . H o w e v e r , a small v a r i a t i o n in activation,
ligation, size o f t h e a n c h o r units, force a n d m o m e n t
m a g n i t u d e s c a n significantly h e l p in c o r r e c t i n g m o s t
d e n t a l a s y m m e t r i e s . T h e u s e of a s y m m e t r i c interarch elastics for d e n t a l a s y m m e t r i e s is o f t e n n o t
d i s c r i m i n a t o r y a n d c r e a t e s u n d e s i r a b l e side effects.
A j u d i c i o u s use o f b i o m e c h a n i c s with s i m p l e appliances, such as cantilevers a n d lingual a n d p a l a t a l
arches, can deliver o p t i m a l forces to o b t a i n p r e d i c t a b l e t o o t h r e s p o n s e with m i n i m a l side effects.
REFERENCES
1. Rodgers SF, Eppley BL, Nelson CL, Sadove AM. Hemifacial microsomia: assessment of classification systems.
J Craniofac Surg 1991;2:114-26.
2. Tallents RH, Guay JA, Katzberg RW, Murphy W, Proskin
H. Angular and linear comparisons with unilateral mandibular asymmetry. J Craniomand Disorders 1991;5:135-42.
3. One I, Ohura T, Narumi E, et al. Three-dimensional
analysis of craniofacial bones using three-dimensional
computer tomography. J Cranio Maxillofac Surg 1992;20:4960.
4. Melnik AK. A cephalometric study of mandibular asymme-
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7.
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9.
10.
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